Cognitive Assessments for Older Adults: Which Ones are Used by Canadian Therapists and Why

Assessments of Functional Cognition Used with Patients following Traumatic Brain Injury in Acute Care: A Survey of Australian Occupational Therapists

This study aimed to describe how occupational therapists working in acute care settings in Australia assess cognitive function in patients with TBI, the influences on assessment choice, and clinician perceptions of performance-based assessment. An online survey was completed by 81 occupational therapists. The most common method of cognitive assessment was reported as non-standardized observation of functional tasks (94.7%), followed by carer-report / self-report (93%). Despite their being positive perceptions of performance-based assessment there was limited use in practice. Assessment use was impacted by practical and organizational constraints including access to assessment resources, time and the built environment in acute care.

The power of observation. Occupational therapists' descriptions of doing observations of people with cognitive impairments in the context of community practice

BACKGROUND

Observation is an important method for occupational therapists (OTs) to gather information on people's occupational performance; yet, not much research has been conducted on OTs' descriptions of doing observations in their practices.

AIMS

This study aimed to explore community OTs descriptions of doing observations during the assessment of persons with cognitive impairments.

MATERIAL AND METHODS

Nineteen OTs participated in focus group interviews. Thematic analysis with an inductive approach was performed.

RESULTS

Three themes were revealed during analysis, the value of doing unstructured observations, the importance of doing observations in familiar contexts, and the importance of experience, structure and competence when doing observation.

CONCLUSIONS AND SIGNIFICANCE

This study showed that the participants regarded observation as one of OTs' core competencies, and they described doing observations in different ways. The results emphasised the importance of doing unstructured observations in persons' familiar contexts when assessing persons with cognitive impairments. However, the participants highlighted the need for increasing OTs structure and competence through implementing more occupation-based standardised assessment tools for OTs in community services to facilitate evidence-based practice.

The Performance Assessment of Self-Care Skills to Predict Adverse Events Post-Discharge

Background. The Performance Assessment of Self-Care Skills (PASS) is a standardized assessment of the ability to perform daily activities. Purposes. This preliminary exploratory study aimed to 1) explore the ability of four PASS tasks to predict adverse events (readmissions and injuries) in older adults following hospitalization; 2) compare PASS's predictive validity to that of a generic tool (SMAF) and OT clinical judgement. Method.Twenty-two older patients were assessed in hospital at discharge and at home one week later. Adverse events were documented for six months post-discharge. Sensitivity and specificity analyses (ROC curves, Fisher's exact tests) were performed. Findings. Two PASS tasks (telephone, medication), the SMAF-Social and OT clinical judgement could identify individuals at risk of readmission (AUC > 0.7; p < 0.05). Implications. Using the PASS to assess more cognitively demanding tasks could be a promising way to predict adverse events after discharge, as a complement to clinical judgment.

Cognitive Assessments Used in Occupational Therapy Practice: A Global Perspective

This exploratory study was aimed at evaluating the current status of global occupational therapy practice on the use of assessments for clients with cognitive impairments and providing recommendations for ongoing evidence. We targeted international occupational therapy clinicians working with clients experiencing neurocognitive impairments. 323 occupational therapists from a wide range of clinical practice areas participated in the study. A large number of therapists used noncognitive specific assessments with a focus on functional approaches. The most commonly used standardized assessments were the COPM (56.7%), followed by MMSE (54.2%) and MoCA (45.5%), while the nonstandardized assessments were clinical observation (38.4%) and generic ADL assessment (34.1%). The use of main assessments was significantly different across world regions (p < 0.05), as were the reasons for choosing them (p < 0.05). The occupational therapists' use of assessment tools with clients suffering from neurocognitive impairments is inconsistent across the globe. The identification of international best practices for selecting and implementing proper outcome measures is warranted. It is essential to promote the development of an occupational therapy initiative to support the use of appropriate assessments at the international levels to facilitate consistent best practice.

Measurement properties of instruments to assess mental function during activity and participation in individuals surviving traumatic brain injury: A systematic review protocol

Background: Most studies assessing mental function in individuals with traumatic brain injury (TBI) assess the impairments through pen and paper tests. However, weak correlation has been found between the results from pen and paper tests and the results from performance-based tests during activity and participation. Objective: To investigate measurement properties of performance-based instruments that are used to assess mental function during activity and participation in individuals with a TBI. Material and methods: PubMed, EMBASE, CINAHL, PsycINFO, and OTseeker will be searched for relevant studies reporting on measurement properties of performance-based instruments to assess mental function in individuals with a TBI. The COnsensus-based Standards for selection of Health Measurement Instruments (COSMIN) checklist will be used to evaluate the methodological quality of the included studies. The Terwee quality criteria will be applied to evaluate the study findings for each measurement property. To summarize all the evidence, a best evidence synthesis will be performed. Results: Results will be presented in text and tables. Conclusions: Conclusion will be drawn up-on the overall evidence Significance: It is expected that the findings of the review will provide evidence to guide clinicians in the selection of instruments to use in occupational therapy practice and research.

[Overview of the assessment practices of occupational therapists working in Quebec]

BACKGROUND.

In occupational therapy practice, client assessments are essential for establishing treatment priorities and determining the effectiveness of interventions. However, occupational therapists' assessment practices are not well documented.

PURPOSE.

This work aimed to provide an overview of the assessment practices of Quebec occupational therapists based on the person-environment-occupation components and clienteles.

METHOD.

A cross-sectional survey was conducted using an online survey that was sent to occupational therapists in Quebec.

FINDINGS.

In paediatrics, occupational therapists tend to use standardized tools to assess physical and neurological abilities. Adult assessment focuses mainly on physical abilities and productivity. For seniors, assessment focuses mainly on functional aspects (physical abilities, personal care, and home safety) and screening for cognitive difficulties.

IMPLICATIONS.

Occupational therapy assessment mostly focuses on physicial abilities. To ensure a holistic approach, more occupational and environmental components should be included in the assessment practices.

Association between older adults’ functional performance and their scores on the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA)

Purpose

The paper aims to investigate if the performance of older adults on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) were associated or predictive of their functional performance in a geriatric evaluation and management (GEM) inpatient hospital setting. This will inform the occupational therapy assessment and management of older adults admitted to sub-acute GEM settings.

Design/methodology/approach

In all, 20 participants (11 men, 9 women, mean age 82 years, SD = 6.93) were recruited from a GEM ward in an Australian hospital. Participants’ cognitive abilities were assessed using the MMSE and MoCA, and their functional performance were assessed using the Functional Independence Measure (FIM). Spearman’s rho correlations and linear regression analyses were completed. Bootstrapping was applied to the regression analyses to accommodate the small study sample size.

Findings

No statistically significant correlations were obtained between the total and subscale scores of the MMSE and FIM or between the total and subscale scores of the MoCA and FIM. In other words, the cognitive and functional abilities of older adults admitted to a GEM setting were not significantly associated in this study.

Originality/value

The findings suggest that the MoCA and the MMSE were not predictive of participants’ functional performance as measure by the FIM in a sub-acute GEM setting. Occupational therapists should be cautious when interpreting participants’ MMSE, MoCA and FIM results and not depend solely on these results in the goal setting and intervention planning processes for clients on GEM wards. Further studies are recommended to confirm these findings.

Systematic Review of Measurement Property Evidence for 8 Financial Management Instruments in Populations With Acquired Cognitive Impairment

OBJECTIVES

To critically appraise the measurement property evidence (ie, psychometric) for 8 observation-based financial management assessment instruments.

DATA SOURCES

Seven databases were searched in May 2015.

STUDY SELECTION

Two reviewers used an independent decision-agreement process to select studies of measurement property evidence relevant to populations with adulthood acquired cognitive impairment, appraise the quality of the evidence, and extract data. Twenty-one articles were selected.

DATA EXTRACTION

This review used the COnsensus-based Standards for the selection of health Measurement Instruments review guidelines and 4-point tool to appraise evidence. After appraising the methodologic quality, the adequacy of results and volume of evidence per instrument were synthesized. Measurement property evidence with high risk of bias was excluded from the synthesis.

DATA SYNTHESIS

The volume of measurement property evidence per instrument is low; most instruments had 1 to 3 included studies. Many included studies had poor methodologic quality per measurement property evidence area examined. Six of the 8 instruments reviewed had supporting construct validity/hypothesis-testing evidence of fair methodologic quality. There is a dearth of acceptable quality content validity, reliability, and responsiveness evidence for all 8 instruments.

CONCLUSIONS

Rehabilitation practitioners assess financial management functions in adults with acquired cognitive impairments. However, there is limited published evidence to support using any of the reviewed instruments. Practitioners should exercise caution when interpreting the results of these instruments. This review highlights the importance of appraising the quality of measurement property evidence before examining the adequacy of the results and synthesizing the evidence.

The conflicted practice: Municipal occupational therapists' experiences with assessment of clients with cognitive impairments

BACKGROUND

The practice of Norwegian occupational therapists (OTs) in municipal practice is a little explored area and with the Coordination Reform Act from 2012, Norwegian OTs in municipal practice have received responsibilities concerning clients with cognitive impairments. The aim of this study was to explore municipal OTs experiences with assessment of clients with cognitive impairments.

METHOD

Fourteen individual interviews with OTs who worked with clients with cognitive impairments, were conducted. An inductive thematic analysis, using text condensation and coding, was performed.

RESULTS

The results revealed three themes; power of occupation, advantages and disadvantages of assessments used and the need for competencies within municipal services. The participants emphasized using observation in the assessment process and reflected on pros and cons of the standardized assessment tools they used. They expressed a need for competence development, although it was difficult to prioritize to do so.

CONCLUSION

This study illustrated a conflicted practice related to choices OTs make in their practices. They valued the importance of working occupation based, however, they chose to use impairment based standardized assessments. They expressed a need to engage in professional development, but due to heavy workloads, the limited power they experienced and lack of knowledge, this was difficult.

Cognitive assessment: A challenge for occupational therapists in Brazil

Cognitive impairment is a common dysfunction after neurological injury. Cognitive assessment tools can help the therapist understand how impairments are affecting functional status and quality of life.

OBJECTIVE

The aim of the study was to identify instruments for cognitive assessment that Occupational Therapists (OT) can use in clinical practice.

METHODS

The instruments published in English and Portuguese between 1999 and 2016 were systematically reviewed.

RESULTS

The search identified 17 specific instruments for OT not validated in Brazilian Portuguese, 10 non-specific instruments for OT not validated in Brazilian Portuguese, and 25 instruments validated for Portuguese, only one of which was specific for OT (Lowenstein Occupational Therapy Cognitive Assessment).

CONCLUSION

There are few assessment cognitive tools validated for use in the Brazilian culture and language. The majority of the instruments appear not to be validated for use by OT in clinical practice.

Assessment of clients with cognitive impairments: A survey of Norwegian occupational therapists in municipal practice

BACKGROUND

With the Coordination Reform Act initiated in 2012, Norwegian occupational therapists in municipal practice have been given responsibilities concerning clients with cognitive impairments. With emphasis on supporting best practice, the aim was to investigate the practice of Norwegian municipal occupational therapists (OTs) in their assessment of clients with cognitive impairments.

METHOD

An online questionnaire was used to collect data from 497 of 1367 OTs in Norwegian municipalities (RR = 36%) Results: The most frequently used methods were informal interviews (91%), observations (91%) and standardized assessments (73%). The most frequently used standardized assessments were the Clock Drawing test (60%) and the Mini Mental State Examination (MMSE 59%). The most common reasons for using standardized assessments were to get a better foundation for initiating interventions (74%), to get more reliable results (64%) and to measure the effect of interventions (47%). The most common reasons for not using standardized assessments were that they did not have competence (49%) or that they did not have access to the materials (40%).

CONCLUSION

The results indicate that there are challenges when it comes to the methods and standardized assessments used. These findings invite further research on enabling municipal OTs to move further towards evidence-based practice.

Determining client cognitive status following mild traumatic brain injury

BACKGROUND

People with mild traumatic brain injury (mTBI) commonly experience cognitive impairments. Occupational therapists working in acute general hospitals in Australia routinely access client Glasgow Coma Scale (GCS) scores, and assess cognitive status using standardized tools and by observing basic activity of daily living (ADL) performance. However, limited evidence exists to identify the best assessment(s) to determine client cognitive status.

AIM/OBJECTIVES

To determine whether cognitive status assessed by GCS score and the Cognistat are predictive of basic ADL performance among clients with mTBI in an acute general hospital and make inferences concerning the clinical utility of these assessment tools.

MATERIAL AND METHODS

Retrospective analysis of medical record data on demographics, Cognistat, GCS, and modified Barthel Index (MBI) using descriptive statistics, chi-square tests and linear regression.

RESULTS

Data analysis of 166 participants demonstrated that no associations exist between GCS and Cognistat scores, or Cognistat scores and MBI dependency level. The presence of co-morbid multi-trauma injuries and length of stay were the only variables that significantly predicted MBI dependency level.

CONCLUSION AND SIGNIFICANCE

While the MBI scores are of value in identifying clients with difficulty in basic ADLs, Cognistat and GCS scores are of limited use in differentiating client levels of cognitive impairment and the authors caution against the routine administration of the Cognistat following mTBI. Further research is required to identify more suitable assessments for use with a mTBI population.

Identification and assessment of functional performance in mild cognitive impairment: a survey of occupational therapy practices

BACKGROUND/AIM

Despite the amount of research evidence pointing to functional changes experienced by individuals with mild cognitive impairment (MCI), we still do not understand how occupational therapists are currently addressing these concerns. Thus, we designed a national study to investigate Canadian occupational therapists practices with this clientele.

METHODS

We conducted a Canada-wide online survey to investigate occupational therapists' practices with clients with potential MCI. Clinicians were prompted by a case vignette that described two clients: one vignette included cues associated with amnestic MCI (aMCI), the other non-amnestic MCI (naMCI). Specifically, clinicians were asked to identify potential concerns and to indicate the screening and assessment tools they would use in clinical practice.

RESULTS

Two hundred and eighty-five participants met the inclusion criteria and were included in the final analysis. The average clinician age was 38.6 (SD = 10.3), 92% were female and 71.2% worked full-time. Almost all clinicians identified a concern in both vignettes, with cognitive concerns being identified more frequently than functional concerns [i.e. Instrumental Activities of Daily Living (IADL) concerns]. In terms of assessment practices, 18 standardised IADL assessments and 10 standardised cognitive assessments have been reported.

CONCLUSION

Encouragingly, almost all clinicians identified a concern. However, some are still missing the IADL cues. Moreover, the lack of consensus in terms of which assessment practices to employ indicates that clinicians might benefit from guidelines in this area of practice.

Cognitive assessment across the continuum of care: the importance of occupational performance-based assessment for individuals post-stroke and traumatic brain injury

BACKGROUND/AIM

When working with individuals following stroke or traumatic brain injury, an important role of the occupational therapist is to assess the impact of cognitive impairment on their ability to engage in occupations and resume important life roles. The aim of this study was to survey therapists' reasons for selection of and challenges with using various cognitive assessment approaches, across the continuum of care, when working with individuals following stroke and traumatic brain injury.

METHODS

A cross-sectional survey, completed via post or online, with responses from 209 Australian occupational therapists was conducted. Participants included clinicians working in acute, inpatient rehabilitation and community settings.

RESULTS

Occupational performance-based assessments were ranked as the most important assessment method, with 69% of participants reporting using these assessments for more than 75% of their clients with cognitive impairment. Participants identified the lack of quantitative data provided by these assessments as a frequent challenge. The identification of cognitive deficits was the highest ranked reason for using cognitive screens and batteries. Challenges identified with using cognitive screens and batteries included difficulty linking assessment results to occupational performance, and difficulty using results to generate intervention strategies. The majority of participants reported using a combined approach to assessment, and used screens and batteries to support findings of occupational performance-based assessments.

CONCLUSIONS

Targeted efforts to further incorporate standardised occupational performance-based methods into clinical practice, research, and ongoing professional development is required to enhance occupational therapy services when working with individuals with cognitive impairment.

Examining the construct validity of the Cognitive Competency Test for occupational therapy practice / Évaluer la validité de construit du Cognitive Competency Test en fonction de la pratique de l’ergothérapie

Background.

Enhancing occupational therapy practice requires critical examination of assessment tools and the conclusions being drawn from their use. When working with cognitively impaired older individuals, judgments about occupational competence are often informed by an assessment of cognitive competence.

Purpose.

The Cognitive Competency Test (CCT) is a frequently used measure in Canada to inform predictions of occupational competence. However, there is an absence of published evidence that addresses its validity.

Methods.

To appraise validity of the CCT, a retrospective chart review ( n = 107) of CCT reports for inpatient and outpatient clients with cognitive impairment was conducted. Data were subjected to exploratory factor analyses to examine the factor structure, and the measure was compared with commonly used clinical variables reflecting cognitive and occupational competence.

Findings.

Results suggest that the CCT measures a unitary construct and provide some support for its predictive capacity.

Implications.

CCT scores can add incremental validity to cognitive screens, such as the Mini Mental State Exam, when evaluating occupational competence.

Validity of predischarge measures for predicting time to harm in older adults

Background.

Concern is often expressed about the ability of persons with cognitive impairment to manage safely after discharge home from hospital. Measures validated for predicting safety are required.

Purpose.

The purpose of this study was to determine whether two predischarge functional measures were valid for predicting time to incident of harm after discharge.

Method.

Participants ( n = 47) were recruited from an inpatient rehabilitation unit. The Assessment of Motor and Process Skills (AMPS) and Cognitive Performance Test (CPT) were administered in hospital. Incident-of-harm outcome was measured by caregiver telephone questionnaire monthly for 6 months.

Findings.

Compared with all independent variables, AMPS Process scale was the best single predictor of time to incident of harm ( p = .01). CPT had a high specificity (91%) for identifying persons who did not have harm.

Implications.

Both AMPS and CPT demonstrated predictive validity for harm outcome over less predictive variables, such as comorbidities and activities-of-daily-living burden of care.

Administration of the Canadian Occupational Performance Measure: effect on practice

BACKGROUND

The Canadian Occupational Performance Measure (COPM) is recommended as a systematic approach to identify issues and determine client progress in occupational therapy, yet little empirical evidence is available that supports this practice.

PURPOSE

To determine if COPM administration was associated with changes in eight dimensions of occupational therapy practice.

METHODS

Twenty-four occupational therapists on eight geriatric rehabilitation sites completed a before-and-after study with a repeated baseline. The eight practice dimensions were assessed after three months of usual care (no COPM use) and after three months of intervention (COPM use) using chart stimulated recall (CSR) interviews and chart audit.

FINDINGS

Mean practice scores for CSR interviews indicated a statistically significant practice improvement (p < .0001) across the eight dimensions, including knowledge of client perspective, clinical decision making, clinician ability to articulate outcomes, and documentation. Chart audit indicated that COPM use resulted in identifying more occupation-focused issues.

IMPLICATIONS

COPM administration could improve occupational therapy practice.

Convergent Validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST) with Two other Cognitive-Perceptual Tests

Background:

It is common for individuals with a neurological impairment, such as a stroke, to present with cognitive-perceptual impairments. The early identification of such problems can assist with rehabilitation efforts. Standardised cognitive and perception tests are often used by practitioners to make such identifications; therefore, it is important to examine the measurement properties of these tests.

Objective:

This study investigated the convergent validity of the Occupational Therapy Adult Perceptual Screening Test (OT-APST) with two other cognitive-perceptual tests: the Neurobehavioural Cognitive Status Examination (Cognistat) and the Developmental Test of Visual Perception — Adolescent and Adult (DTVP-A). The Cognistat is primarily a test of cognition but has some subscales that evaluate perceptual skills. The convergent validity between the Cognistat and the DTVP-A was also investigated. It is imperative that tests used by therapists have documented validity to ensure that the results obtained actually measure the skills and abilities that the tests claim they measure.

Method:

Thirty-two adult patients, ranging in age between 46 and 91 years (mean = 73, SD = 4.6) with a primary diagnosis of stroke, completed the OT-APST, the Cognistat and the DTVP-A. Spearman's rho was used to analyse the correlations between the tests' subscales.

Results:

Three of the Cognistat subscales were significantly correlated with OT-APST subscales: Cognistat Constructional Ability and OT-APST Body Scheme; Cognistat Memory and OT-APST Functional Skills; and Cognistat Calculations and OT-APST Body Scheme. Only one of the OT-APST subscales, Body Scheme, had statistically significant correlations with the DTVP-A's Figure-Ground, Visual-Motor Search and Visual Closure subscales. There were significant correlations between the Cognistat's Constructional Ability and Judgment subscales and five of the six DTVP-A's subscales.

Conclusion:

Given that only a few of the subscales from the Cognistat and DTVP-A were significantly correlated with those of the OT-APST, this indicates that many of the constructs assessed by the three tests are not associated; hence, limited convergent validity evidence for the OT-APST was present. Further inquiry is required because it is important that such instruments are assessing what they purport to test, particularly when they are used to determine clients' strengths and weaknesses in clinical practice.

National survey of Canadian occupational therapists' assessment and treatment of cognitive impairment post-stroke

AIM

This study examined variations in management of cognitive impairment post-stroke among occupational therapists and factors associated with variations in practice.

METHODS

Canada-wide cross-sectional telephone survey. Clinicians' practices were examined using standard patient cases (vignettes).

SETTING

Acute care, inpatient rehabilitation and community-based sites providing stroke rehabilitation in all Canadian provinces.

PARTICIPANTS

Occupational therapists (n=663) working in stroke rehabilitation as identified through provincial licensing bodies.

MAIN OUTCOME MEASURES

Type and frequency of cognition-related problem identification, assessment and intervention use.

RESULTS

Respectively, 69%, 83% and 31% of occupational therapists responding to the acute care, inpatient rehabilitation and community-based vignettes recognised cognition as a potential problem. Standardised assessment use was prevalent: 70% working in acute care, 77% in inpatient rehabilitation and 58% in community-based settings indicated using standardised assessments: 81%, 83% and 50%, respectively, indicated using general cognitive interventions.

CONCLUSION

The Mini-Mental State Examination was often used incorrectly to monitor patient change. Executive function, a critical component of post-stroke assessment, was rarely addressed. Interventions were most often general (e.g. incorporated in activities of daily living) rather than specific (e.g. cueing, memory aids, computer-based retraining).

Actual reality: a new approach to functional assessment in persons with multiple sclerosis

OBJECTIVE

To examine the use of an innovative approach for assessing everyday life activities of people with multiple sclerosis (MS): Actual Reality. Actual Reality is a performance-based assessment approach that involves the use of the internet to perform real, everyday life activities.

DESIGN

A between-subjects design.

SETTING

Outpatient rehabilitation institute.

PARTICIPANTS

Persons (n=21) with clinically definite MS and healthy controls (HCs) (n=18) without any reported neurologic disabilities participated in this study. Participants were between the ages of 21 to 60 years, and the sample consisted of volunteer sample.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants were asked to access the internet to purchase airline tickets for a round trip flight and were administered the Minimal Assessment of Cognitive Functioning in Multiple Sclerosis. Participants also completed questionnaires to assess quality of life (Functional Assessment of Multiple Sclerosis), functional status (Functional Behavior Profile), and prior Internet experience.

RESULTS

The MS group displayed significantly more difficulties than the HC group in accurately and independently completing the Actual Reality task primarily because of cognitive impairment. Self-report of quality of life and functional status were not correlated with Actual Reality performance in the group of people with MS. However, the self-report measures were significantly associated with affective symptomatology.

CONCLUSIONS

These results provide initial evidence supporting the use of the Actual Reality approach in assessing persons with MS performing everyday life activities. Actual Reality is a significant step forward in increasing the sensitivity, accessibility, and relevancy of functional assessments in people with cognitive and physical disabilities.